The Peacock study: feasibility of the dynamic characterisation of the paediatric hypothalamic-pituitary-adrenal function during and after cardiac surgery

Abstract

Background: Cortisol is the main stress hormone mobilised during surgery to establish homeostasis. Our current understanding of the hypothalamic-pituitary-adrenal axis physiology in children undergoing cardiopulmonary bypass is very limited due to: (1) very few cortisol time point measurements over long periods (2) difficulties of sampling in low weight babies and (3) the concomitant use of glucocorticoids at anaesthesia induction. This lack of understanding is reflected in a lack of consensus on the utility of glucocorticoids perioperatively in cardiac surgery with the use of cardiopulmonary bypass.

Methods: The Peacock Study is a prospective, two-centre, observational cohort study of 78 children (undergoing cardiopulmonary bypass procedures and non-surgical procedures - split by age/cyanosis) that aims to characterise in detail the hypothalamic-pituitary-adrenal axis physiology of children using the stress model of paediatric cardiac surgery. Also, we aim to correlate cortisol profiles with clinical outcome data. We herein describe the main study design and report the full cortisol profile of one child undergoing heart surgery, thus proving the feasibility of the method.

Results: We used an automated, 24-h tissue microdialysis system to measure cortisol and cortisone, every 20 min. We herein report one cortisol profile of a child undergoing heart surgery. Besides, we measured serum cortisol and adrenocorticotrophic hormone at seven-time points for correlation. Tissue concentrations of cortisol increased markedly several hours after the end of surgery. We also noted an increase in the tissue cortisol/cortisone ratio during this response.

Conclusion: We report for the first time, the use of an automated microdialysis sampling system to evaluate the paediatric adrenal response in children. Changes in cortisol and cortisone could be measured, and the concentration of cortisol in the tissues increased after the end of cardiac surgery. The method has wide application to measure other hormones dynamically and frequently without the limitation of the circulating blood volume. The data from the main study will clarify how these cortisol profiles vary with age, pathology, type of procedure and correlation to clinical outcomes.

Trial registration: ISCRTN registry, number: 982586.

Keywords: Cardiopulmonary bypass; Children; Glucocorticoids; Hypothalamus-pituitary-adrenal axis; Paediatric heart surgery.

Fig. 1

The microdialysis system in situ. Sampling in a 6-month-old baby that returned to the paediatric intensive care unit, after heart surgery

Fig. 2

24-h cortisol profile of 2-year-old female undergoing ventricular septal defect. Abbreviations: KTS: knife to the skin, start of operation; CPB time is represented in a red shaded area. KOS – knife of skin time – end of the operation. In dotted green lines are illustrated the serum cortisol levels taken at the reference time points (seven). In the purple dotted line, the ACTH serum concentration taken at the reference time points (seven) is illustrated. On the right Y-axis, the serum cortisol/ACTH concentration is depicted. The blue, line denotes the tissue cortisol and the red line the tissue cortisone levels taken every 20 min using microdialysis